A 36-Year-Old Woman With Cramping and Diarrhea

Alexander Potashinsky, MD; John W. Birk, MD

Disclosures

March 20, 2018

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 36-year-old woman with a medical history that includes hypertension and Hashimoto thyroiditis presents to a gastroenterologist's office for recurrent diarrhea. For the past 2 years, she has experienced diffuse abdominal cramping and discomfort after eating. This has been associated with bloating and increased flatulence. She describes having three soft stools almost daily.

Other than her loose stools, her most troublesome symptom is a "foggy brain," which she has about 4 days a week. This is described as a feeling of reduced memory, delayed thinking/focus, and difficulty staying awake. She has also noticed intermittent muscle and joint aches.

The patient denies fever, significant change in weight, temperature sensitivity, blood in her stool, or any rashes. She has no family history of any gastrointestinal issues, including gastrointestinal (GI) cancer, inflammatory bowel disease or celiac disease. She has never had endoscopy or colonoscopy but has had normal "routine" blood work in the past.

She has tried changing her diet, including cutting out dairy and gas-producing foods, with limited success. Over the past 3 months, she has tried cutting out bread and other gluten-containing products. After stopping gluten-containing foods, she felt her symptoms quickly improve. Her primary care doctor performed serology for celiac disease, but results were negative. She restarted eating gluten-containing food and had a gradual return of her diarrhea and "foggy brain."

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